Current opinion in critical care
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Curr Opin Crit Care · Aug 2018
ReviewChanging paradigms in metabolic support and nutrition therapy during critical illness.
To summarize the most recent advances in acute metabolic care and critical care nutrition. ⋯ These new findings will probably change the practice of metabolic and nutrition therapy in critical illness and challenge paradigms advocated for long.
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Full nutritional support during the acute phase of critical illness has traditionally been recommended to reduce catabolism and prevent malnutrition. Approaches to achieve full nutrition include early initiation of nutritional support, targeting full nutritional requirement as soon as possible and initiation of supplemental parenteral nutrition when enteral nutrition does not reach the target. ⋯ A two-phase approach for nutritional support may more appropriately account for the physiologic changes during critical illness than one-phase approach. Further evidence is awaited for the optimal protein amount during critical illness and for feeding patients at high nutritional risk or with acute gastrointestinal injury.
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To help guide metabolic support in critical care, an understanding of patients' nutritional status and risk is important. Several methods to monitor lean body mass are increasingly used in the ICU and knowledge about their advantages and limitations is essential. ⋯ Methods to monitor lean body mass in the ICU are under constant development, improving upon bedside usability and offering new modalities to measure. This provides clinicians with valuable markers with which to identify patients at high nutritional risk and to evaluate metabolic support during critical illness.
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Glucagon is known as a key hormone in the control of glucose and amino acid metabolism. Critical illness is hallmarked by a profound alteration in glucose and amino acid metabolism, accompanied by muscle wasting and hypoaminoacidemia. Here we review novel insights in glucagon (patho)physiology and discuss the recently discovered role of glucagon in controlling amino acid metabolism during critical illness. ⋯ Glucagon plays a crucial role in amino acid metabolism during critical illness, with an apparent feedback loop between glucagon and circulating amino acids. Indeed, elevated glucagon may, to a large extent, be responsible for the hypoaminoacidemia in the critically ill and infusing amino acids increases glucagon-driven amino acid breakdown in the liver. These novel insights further question the rationale for amino acid administration during critical illness.
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Sepsis leads to a complex intramyocardial inflammatory response that results in sepsis-induced myocardial dysfunction. Here, recent findings are reviewed in a physiologic context. ⋯ Sepsis-induced myocardial dysfunction is increasingly recognized as a major contributor to outcome of septic shock. Significant strides have been made in understanding the intramyocardial inflammatory response that causes myocardial dysfunction. A number of novel approaches show promise by modulating the intramyocardial inflammatory response.